Prof Umeed’s Qs on Bipolar Disorder

1) DSM Criteria of Manic Episode (Symptoms >2 weeks)

- Irritability
- Elated mood
- Grandiosity
- Increased Goal Directed Activities
- Reduced Need for Sleep
- Flight of Ideas
- Talkativeness
- Excessive involvement in pleasurable activities (i.e shopping)
2) What is the most common/significant symptom in Mania? Irritability (Feeling of Agitation). Because
Mania is a mood disorder so, the most important symptom must be symptom that is mood-related.
(Second most significant/exclusive symptom in mania is Elation)
3) Definition of Elation: Long lasting excessive happiness leading to over activity.
4) Definition of Reduced Need for Sleep: Patient requires only minimal amount of sleep at night (2-3hrs)
yet feeling energetic the next day.
5) Definition of Increased Goal directed Activities: Taking on a lot of new projects in excess of baseline.
6) Definition of Grandiosity: A belief that one has super powers beyond those of a normal person.
7) In Past Psychiatry History: What do you want to know about patient’s first onset of illness.
- How many years ago? Duration of the first episode.
- What symptoms patient had at that time? Was it similar to the current symptoms?
- How long patient was admitted in the ward?
- What medication was given? Is patient discharged with medication?
- Whether patient goes back to baseline functioning. (Social, Occupational Function, Self Care)
8) What is the normal duration of first onset of Bipolar disorder? 3-6 months
9) How to differentiate Manic or Schizophrenia?
- Progression of first episode. With or without treatment, Manic resolves in 3-6 months. If symptoms
persist after 6 months- diagnosis is likely to be Schizophrenia.
- Ask about longitudinal history since first onset.
- More functional impairment in Schizophrenia
- More bizarre symptoms in Schizophrenia.
- 10-20% of patients can’t be differentiated mania or Schizophrenia
10) In Past Medical & Surgical History. Why need to ask history of Diabetes, Hypertension, and Epilepsy?
Side effect of medications. (Atypical Anti Psychotic – Metabolic side effects). Certain drugs (Anti
depressants) lower seizures threshold so dangerous for patient with history of epilepsy.
11) In Family History. Why family history of Diabetes important? Side effects of Atypical Anti-psychotics.
Also, studies have shown people with family history of HTN and DM have higher risk of getting
Schizophrenia. If there is family history of mental illness, Ask: Any similarities and difference in
symptoms of patient and that family member.
12) Personal History. For Pre-Morbid personality, why can’t we rely on information given by patient?
Because patient may be having symptoms during the interview and he may be confused between her
pre-illness personality and current state.
13) Which pre-morbid personality significant in Bipolar Disorders? Cluster B personality
14) On Physical Examination. BMI important to check in Manic Patient. Weight gain is the side effect of
Lithium and Risperidone.
15) On MSE. What positive finding you expect from a Manic Patient?
- Flight of Ideas: Rapid, shifting of two consecutive ideas that have superficial connection (Rhyming
punning and words of same class)
16) -Grandiose Delusions: A belief that one has super powers beyond those of a normal person.

- Pressured Speech: Rapid, Loud and difficult to interrupt speech

- Labile Mood: Sudden exaggerated short loved emotion
- Distractibility: Inability to focus on the most important things.
17) Can psychotic symptom present in mood disorders? YES.
18) Is the delusion present in this patient mood congruent or incongruent? MOOD CONGRUENT. What is
mood congruent? When patient have delusions or hallucinations due to underlying mood disorders.
The delusion is related to changes of emotion.
- Depression causes psychotic themes of paranoia, worthlessness
- Mania : Grandiose delusions, Invincibility
19) Which one psychotic symptom/delusion type that may be present in Manic patient? Paranoid
delusions because they usually think they are rich, popular, above everyone else so, they tend to think
that other people are going after them.
20) In patient diagnosed with Bipolar Disorders, are they are at risk of developing Schneider's first rank
symptoms? YES. Percentage of Bipolar patient will develop Schneider’s First Rank symptoms? 10-
20%
21) What are Schneider’s First Rank symptoms?
- Auditory Hallucination
- Through broadcast/Insertion
- Delusion of Control
- Delusional Perception
22) What is one single most important cognitive test we should do/may be impaired in Manic patient?
-Poor Concentration. Manic patient tend to have impaired concentration due to distractibility.
23) In what other psychiatric disorders Labile Mood may be present?
- Post partum depression
- Dementia
- Mixed episodes of mood disorders.
24) Irritability in Schizophrenia vs. Mania?
Schizophrenia: Type of illness
Bipolar: Due to mood, provoke?*
25) What is Rapid Cycling? Occurrence of 4 or more mood episodes in 1 year (Depression, Mania or
Hypomania) Gold standard treatment for Rapid Cyclers? Valproate
26) Why manic episode is considered Emergency (and may necessitate hospitalization)? Severely
impaired judgement can make a manic patient dangerous to self and others.
27) What is hypomania? Difference between mania and hypomania? Hypo manic episode has similar
symptoms as in manic except it’s duration is shorter (<1week)
Mania : Lasts at least 7 days (HM: at least 4 days)
: Causes severe impairment in social/occupational functioning. (HM: No marked
impairment)
: May necessitate hospitalization (HM: Not required)
: May have psychotic features. (HM: No psychotic features)
28) What is Mood Disorder with Mixed features? Also known as Dysphoric Mania. People with Dysphoric
mania experience symptoms of depression and mania or hypomania (a milder form of mania) at the
same time. Poor response to Mood Stabilisers (Lithium). Anti-convulsants( Valproic Acid) is more
helpful for this type.
29) Important Pre-testing before giving Lithium: BMI, ECG, Renal Function, RP, FBC, Blood Serum Lithium,
Creatinine level.
30) Lithium is gold standard treatment for Bipolar, but why most Bipolar patients in HKL are given
T.Epilim(Valproate). Lithium has very narrow therapeutic index and more serious side effects(renal
impairment) than Valproate. Thus, needs more monitoring pre, during and post administration.
31) What is the normal response of Manic patient to treatment? They don’t like taking medications.
Because they feel that they will lose the high energy drive, elated mood, grandiosity, high motivation if
they consume medications. They don’t like any interference that dampen their energy drive. They feel
they need to complete so many things.
32) Difference between Bipolar Disorder I and II?
Bipolar I: Known as Manic Depression. Involves episode of mania and major depression however,
episode of depression is not required for diagnosis.
Bipolar II: Known as Recurrent Major depressive episodes with hypomania. NO MANIA EPISODE.
33) Drugs that can induce Bipolar : Anti depressants, Sympathomimetics, Dopamine, Corticosteroids,
Levodopa, Coccaine, Amphetamines
34) Medical Conditions that can cause Mania : Hyperthyroidism, Neurological Disorders(Temporal Lobe
Seizures, MS), Neoplasms, HIV.
35) Prognosis of Bipolar :
- The course is usually chronic with relapses. As the disease progresses episodes may occur more
frequently
- 60% of patients will recover recover , 30% will have relapses or progress into schizoaffective disorder.
36) Management in HKL ward : T. Epilim 400mg BD, T.Risperidone 2mg ON
37) Side Effects of Risperidone
Metabolic Changes (4H’s) –Hyperglycemia, Hyperlipidemia, Hyperprolatinemia, Weight Gain
Orthostatic Hypotension
38) Side Effects of T.Epilim (Sodium Valproate)
-Weight Gain
- Hepatotoxicity
- Teratogenic effects (Spina Bifida!)
39) Why Benzodiapines is sometimes given for Bipolar patient? To treat Insomnia. (Commonly given BDZ:
Lorazepam, Clonazepam)
40) How Lithium can further complicates Bipolar Disorder? By causing Hypothyroidism.